Khazanah Riset

Determinants Associated with The Clinical Performance of Health Workers in The Implementation of Patient Safety in Inpatient Gatot Subroto Army Hospital in 2015 Prihadi Estu Widodo, Susilowati Abstract Objectives : This study aims to assess the determinant factors related to the clinical performance of health workers based on the implementation of international JCI accreditation standards IPSG at Gatot Subroto Army Hospital in 2015, which is expected to be useful for input to the Gatot Subroto Army Hospital description of the results of the evaluation of the consistency of clinical performance of health workers based on the application of achievement IPSG implementation JCI international accreditation standards that have been implemented on an ongoing basis. Methods : This study uses the correlative analytic method. These samples included 91 respondents, using a sampling method with Taro Yamane formula. The experiment was conducted in May 2015. The data were analyzed with Chi Square test and logistic regression analysis using SPSS. Results : In the bivariate analysis of the variables of knowledge, attitude, leadership roles, reporting systems and the availability of facilities has proved a significant association with p value of <0.05, while the motivation variable was not significantly associated evidenced by the value of p> 0.05. In the multivariate analysis, respectively greatest effect on performance is variable Leadership Role (4.726), Knowledge (3.458), attitude (3.221) and Availability Facility (1,674). These four factors need attention from the Hospital Management by taking into account other factors that health personnel were able to improve performance and patient safety into the work culture in the hospital. Conclusions : The results showed that the influence of Knowledge, Attitude, Leadership Roles, Reporting System and Facility Availability on Performance was 27.9% while 72.1% could be explained by other variables both from internal and external factors of Health Workers. In the order of greatest influence on performance are the variables of Leadership Roles (4,726), Knowledge (3,458), Attitudes (3,221) and Facility Availability (1,674). Other internal and external factors need to be developed from individual Health Workers to produce good performance. Keywords : Performance, Medicals, Knowledge, Attitude, Motivation, Leadership, Roles, Reporting System, Availability Facility 172

Determinants Related to The Work Behavior of Doctors at The Gatot Soebroto Army Central Hospital in 2015 Hardjanto, Susilowati Abstract Objectives : The design of this study was to determine and analyze the direct and indirect effects of leadership style, organizational culture and work motivation on the work behavior of doctors in the implementation of JCI international accreditation standards at the Gatot Soebroto Army Central Hospital in 2015. Methods : This study uses a correlative analytic method. The research sample of 80 respondents, using a sampling method with the formula Taro Yamane. The study was conducted from April to June 2015. Data were analyzed by Chi Square test and logistic regression analysis using SPSS. Results : In the bivariate analysis of organizational culture variables, leadership style, work motivation on the doctor's work behavior has a significant relationship evidenced by p <0.05. In multivariate analysis, the most influential effect on performance are organizational culture variables (0.362), leadership style (0.239) and work motivation (0.161). These three factors need to get the attention of the Hospital Management while continuing to pay attention to other factors so that doctors are able to improve work behavior at the hospital. Conclusions : The results showed that the influence of leadership style, work motivation and organizational culture variables on doctor's work behavior was 30.1% while 69.9% could be explained by other variables both from internal and external factors of the doctor. In order the greatest influence on work behavior are organizational culture variables (0.362), leadership style (0.239) and motivation (0.161). Other internal and external factors need to be developed from individual doctors to produce good work behavior. Keywords: Doctor's Work Behavior, Work Motivation, Leadership Style, Organizational Culture 173

Evaluate The Skills of Health Workers in Basic Life Assistance Actions, Fire Fighting and Hand Hygiene According to The Educational Qualification Standards and Staff of The JCI Accreditation Standards at The Gatot Soebroto Army Hospital in 2015 Made Astiya, Susilowati Abstract Objectives : To maintain the continuity of the implementation of JCI accreditation standards after the assessment related to the competency of health workers which is a benchmark of success in achieving the implementation of educational qualification standards and JCI accreditation standards staff that are assessed regularly in the form of evaluating the skills of health workers in the hospital, namely skills in the act of providing assistance basic life, fire fighting and hand hygiene. Methods : This study uses a correlative analytic method. The research sample of 91 respondents, using a sampling method with the formula Taro Yamane. The study was conducted in May 2015. Data were analyzed by Chi Square test and logistic regression analysis using SPSS. Results : In the bivariate analysis, knowledge, monitoring, hospital policy and monitoring variables have a significant relationship as evidenced by the p value <0.05. In multivariate analysis, the most influential effect on performance is Knowledge (2,352), Competence (2,137) and Monitoring (2,481). These three factors need to get the attention of the Hospital Management while continuing to pay attention to other factors so that Health Workers are able to improve their skills to realize quality services and focus on patient safety at the hospital. Conclusions : The research shows the factors that influence the evaluation and competency of health personnel skills in the implementation of Education and Staff Qualification Standards, namely the skill of implementing Basic Life Assistance, fire fighting and hand hygiene are variables of knowledge, hospital policy, competence and monitoring as evidenced by statistical tests. The results of the study prove that with good personnel knowledge, positive hospital policies, good competence and monitoring from the leaders run well, the evaluation of the skills of health workers in the Inpatient Installation of the Central Hospital of the Gatot Soebroto Army became good. 174

Keywords: Skills Evaluation, Staff Qualification and Education, JCI Standards 175

Determinants Related to Doctor's Visit Compliance According to The Hospital Minimum Service Standards at The Gatot Soebroto Army Central Hospital In 2017 Donny Aldian, Susilowati Abstract Objectives : The purpose of this study was to examine the determinations relating to doctor visits according to Medical Service Standards at the Inpatient Installation of the Central Gatot Soebroto Army Hospital in 2017. Methods : This research is a survey research (non-experimental), where no intervention or treatment of variables is done, then changes are seen in other variables, but merely observing natural or social phenomena that occur, or looking for the relationship of these phenomena with other variables. This research approach is a quantitative descriptive analysis study with a cross sectional design that the researcher wants to find the relationship between the independent variable and the dependent variable by taking a momentary measurement. To achieve the objectives in this study the researchers used the Chi square analytic test. This research was conducted at the Gatot Soebroto Army Hospital consisting of 52 inpatient rooms. Results : The relationship of knowledge variables with doctor's visit compliance showed p value 0.055 (<0.05), then HO was rejected meaning there was a significant / significant relationship between knowledge and doctor's visit compliance. The relationship between attitude variable and doctor's visit compliance showed p value = 0.005 (<0.05), so HO was rejected, meaning that there was a significant / significant relationship between attitude and compliance with doctor's visit. The relationship between motivation variable and doctor's visit compliance showed p value 0.554 (<0.05), so HO failed to be rejected, meaning there was no meaningful / significant relationship between motivation and doctor's visit compliance. Analysis of the relationship between leadership role and doctor's visit compliance shows p value 0.007 (<0.05), then HO is rejected, meaning there is a significant / significant relationship between leadership role and doctor's visit compliance. Conclusions : The results showed that the influence of Knowledge, Attitude and Role of Leadership variables on the Visit Doctor Compliance was 27.9% while 72.1% could be explained by other variables both from internal and external factors of the Doctor. Sequentially the greatest effect 176

on performance is the variable Role of Leadership (4,726), Knowledge (3,458), Attitude (3,221) so it is necessary to develop other internal and external factors from doctors to produce good performance. Keywords: compliance, doctor's visit, hospital minimum service standard 177

The Medicolegal Aspects of Hymen Examination of Rape in RSUP Dr. Hasan Sadikin Bandung Purwanto Panji Sasongko; Noorman Herryadi; Andri Andrian Rusman Abstract Background: The medicolegal aspect of hymen examination, in the alleged victim of \"rape\" is very important, therefore issued by the WHO checking the hymen on the alleged \"rape\" victim, whose contents on hymen examination can be described in the form of hymen, then described its appearance Whether there are loopholes, bumps, notches, thickening of thickening or thinning at the edges of the hymen, and whether there are any remnants of the hymen. \"Rape\" in Latin is rapio which means to seize, which means, the act is done without consent. In this case, there are still differences of views among medical professions about the examination of the appearance of the hymen. This study aims to determine the extent to which WHO guidelines for hymen examination is applied in Dr. Hasan Sadikin Bandung. While the aspect of his gunalaksananya is to be a guide in conducting training and skills improvement on the investigation of victims of alleged \"rape\" and as for law enforcement which is fair and right, so that law enforcement reaches its aim that is justice and truth. Method: The research design used in this research is cross sectional or cross section. Data used in this study is secondary data derived from medical record data in SMF Obstetrics and Gynecology RSUP Dr. Hasan Sadikin Bandung period January 2012-December 2016. To calculate the minimum sample size in this study, the sampling formula used is the number of known population of 99 cases for 5 years, so the minimum sample when calculated using the formula is 50 people. Results: In this study, the number of samples was 79 people with the percentage of hymen examination which describes the gap of 91.14%, the remaining hymen 6.33% and the hymen dideskripsikannya 2.53%. There is a percentage of hymen form of annular 93,6%, semilunar 2,53%, no hymen form 2,53% and not the hymen is 1,27%. Then there is the percentage of compliance according to the WHO guidelines of 97.47% and the unsuitable by 2.53%. From anamnesa, the percentage of vaginal delivery 6.33% and has never given birth 93.67%. 178

Conclusion: The highest percentage describes the gap of 91.14%, not 2.53%. The most hymen percentage was an annular form of 93.67%, not 1.27% described. So the results obtained in accordance with WHO guidelines 97.47%. Keywords: hymen examination, rape, WHO (World Health Organization) guidelines. 179

Characteristics of The Corpse Which Management Based on Specific Emerging Infections in Gatot Soebroto Indonesia Army Central Hospital Purwanto Panji Sasongko, Muhamad Tolib Abstract Background. Based on the Regulation of the Minister of health of the Republic of Indonesia Number 1501 / Menkes / Per / X / 2010 concerning certain types of infectious diseases that can cause epidemics and their mitigation efforts are determined by the Minister. Thus, the 2019-nCov infectious disease in accordance with the Decree of the Minister of Health of the Republic of Indonesia Number HK.01.07 / Menkes / 104/2020 is determined as an infectious disease that can cause an outbreak. Central Army Hospital (RSPAD) Gatot Soebroto became one of the referral Hospitals for the prevention of certain Emerging Infection Diseases in accordance with the Decree of the Minister of Health of the Republic of Indonesia Number HK. 01.07 / Menkes / 169 / 2020. At the Gatot Soebroto Army Hospital there is a Standard Operating Procedure (SPO) regarding the management of remains due to an infectious disease outbreak in accordance with the decision of the Minister of Health. In the management of bodies that are handled according to the SPO at the Gatot Soebroto Army Hospital, there is a body profile based on age and sex. Age categories according to WHO (World Heath Organization) are infants (0-1 years), Children (2-10 years), Teenagers (11-19 years), Adults (20-60 years), Elderly (over 60 years). Method. The age category used in this study is the WHO age category, while the study design used in this study is cross sectional. The data used in this study are secondary data derived from infectious corpse service data at the Gatot Soebroto RSPAD corpse in the March 2020-May 2020 period. To calculate the minimum sample size in this study, a sampling formula for which the population is known is used. as many as 63 bodies were carried out in the process of scavenging the bodies according to the SPO for a period of 3 months, with a minimum sample of 38. The study used a sample of 63. Results. Obtained categories according to the age of the Infants (0-1 years) by 4.76%; Children (2-10 years) at 0%; Teenagers (11-19 years) by 0%; Adult (20-60 years) of 52.38%; and the elderly (> 60 years) by 42.85%. 180

Conclusion. There is the highest percentage in the Adult category (20-60 years) of 52.38%, the Elderly category (> 60 years) of 42.85% and the Infants category (0-1 years) of 4.76%. The genders who died were 71.42% male sex. Keywords: The corpse; Emerging Infectious Diseases (EID); Gatot Soebroto Indonesia Army Central Hospital. 181

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Successful Treatment of Adult Pleomorphic Rhabdomyosarcoma in The Posterior Left Femur: A Case Report Barlian Sutedja, Abdul Muthalib, Ikhwan Rinaldi, Terawan Agus Putranto, Tjondro Setiawan, Diah Rini Handjari, Jubilate Edward I. Tambun, Reza Adiwidjaja Abstract Introduction: Rhabdomyosarcoma (RMS) is the most common childhood soft tissue sarcoma, but it represents only a small portion of soft tissue sarcoma in adult population. There is a treatment protocol based on Intergroup Rhabdomyosarcoma Study (IRS) that provides satisfactory results in treating RMS in children, but there is only limited evidence regarding the outcome and prognosis in extrapolating the IRS protocol to treat RMS in adults. We report a case of adult pleomorphic RMS treated with multidisciplinary approach and the results we have obtained. Case presentation: A 48-year-old woman was admitted in February 2011 due to a painful mass on her left thigh. Diagnosis of pleomorphic rhabdomyosarcoma was made by histopathology and immunohistochemistry. After multimodal treatment that includes Trans- Arterial Chemotherapy Infusion, Cryosurgery, and wide excision surgery, our patient remains disease-free as of the latest annual follow up examination on June 2017. Conclusions: The pleomorphic type of Rhabdomyosarcoma is very rare in adults and is often associated with a poor prognosis. In our case, a multidisciplinary approach with multimodal treatment provides excellent result, even after a routine follow up spanning through six years. Keywords: Rhabdomyosarcoma, Pleomorphic, Adult, Multidisciplinary Approach, Multimodality Treatment, TACI, Cryosurgery, Surgery 185

Fractional Flow Reserve: Nurturing A Functional Perspective in Angioplasty (Case Report) E. Hindoro, V. Pratama, BA. Permana, I. Purnawan, R. Pranata, G. Fonda Abstract Fractional flow reserve (FFR) is an indirect index determined by measuring the driving pressure for microcirculatory flow distal to the stenosis relative to the coronary driving pressure available in the absence of a stenosis. The physiologic criterion for inducible ischemia is FFR< 0.80. We present two interesting cases. Case I: 45 years-old female, with chief complaint of stable angina pectoris CCS II, prior history of hypertension and dyslipidemia. ECG Stress test (+), Echocardiography result was unremarkable (LVEF 68%). CAG showed non-significant stenosis at one- third proximal LAD, FFR showed 0.78. Patient underwent PCI with DES, post-stenting FFR result of 0.95. At 3rd and 6th months follow-up there were no chest pain, no nitrate consumption and negative stress test. Case II: 67 years-old female presented with chief complaint of typical angina. Prior history of diabetes on OADs and statin. ECG stress test was inconclusive; CAG test demonstrated non-significant stenosis in proximal LAD. FFR was 0.88. Patient underwent OMT. At 3rd and 6th months follow-up there were no chest pain, no nitrate consumption and negative stress test. In Case I: there was insignificant stenosis through CAG with significant FFR. Patient underwent PCI, follow-up was excellent. Insignificant stenosis through CAG is misleading and PCI was done and yield excellent post-stent FFR results. In Case 2: there was non-significant stenosis through CAG with insignificant FFR result, patient undergoes OMT with remarkable follow-up results. Studies exhibited various benefits of FFR, significant reduction in major adverse cardiac events at 1st and 5th year. The number of stents placed/patient was significantly higher in the CAG-guided than FFR-guided group. Physiologically FFR-guided PCI was safe, improve cardiac outcomes and cost-effectiveness with reduced number of stents compared to angiographic criteria. It‟s time for “Functional” era. Keywords: Fractional Flow Reserve, Functional, Angioplasty, Angiography, Coronary Artery Disease, Stent 186

Routine Thrombus Aspiration in Primary Percutaneous Coronary Intervention: Is It Still Necessary? (Case Report) R. Pranata, V. Pratama, I. Purnawan, E. Hindoro, G. Fonda Abstract Aspiration thrombectomy has been a modality routinely done during primary PCI, based on TAPAS trial (n=1071) which stated one year cardiac mortality reduced from 6.7% to 3.6%. TASTE Trial (n=7244) and TOTAL trial (n=10,732) showed no differences between 2 treatment groups. Thrombectomy was associated with increased risk of stroke by twofold. We present two interesting cases. 71 years-old male with Anterior STEMI, onset 6 hours before admission. Coronary angiography showed total occlusion in proximal LAD, with thrombus (TIMI 0). Significant stenosis in LM, proximal LCx and RCA. Thrombus aspiration and primary PCI in LAD was done (TIMI 3). Echocardiography data N/A. Second case is 54 years- old male with Acute inferior STEMI, onset 2 hours before admission. Coronary angiography showed total occlusion in RCA (TIMI 0). Significant stenosis in LAD and LCx. Primary PCI of RCA was done (TIMI 3). PCI in LAD was done due to hemodynamic instability (TIMI 3), echocardiography: LVEF 66% and RWMA. Both were clinically and hemodynamically stable after procedure and in 30 days follow up, there was neither recurrent MI, stent thrombosis nor stroke. Second case was scheduled for PCI of LCx 6 months later. Both presented with STEMI. Primary PCI and aspiration thrombectomy was done in first case. Primary PCI without thrombectomy was done in second case. Both were clinically and hemodynamically stable after procedure and in 30 days follow up. There is no incident of stroke, which risk is increased. TASTE and TOTAL trial demonstrated no benefit in performing thrombectomy before primary PCI, with addition of unnecessary increase in stroke risk. 2015 ACC/AHA/SCAI Focused Update on Primary PCI stated that routine aspiration thrombectomy before primary PCI is not useful (Class III, LOE: A). Interventional cardiology is a rapidly evolving field; there has been a shift in dogma regarding interventional management of STEMI as new evidence against performing aspiration thrombectomy surfaced. Keywords: Thrombectomy, Thrombus, Aspiration, STEM I, PCI 187

A Case Report of Primary Percutaneous Coronary Intervention on Multivessel Disease ST Elevation Myocardial Infarct: Why Not CABG After? Abraham Fatah, Wendy Wiharja, Raymond Pranata, Sunanto Ng Abstract More than 50% of ST Elevation Myocardial Infarct (STEMI) occurs with multi-vessel disease (MVD). Such case can be managed with primary percutaneous coronary intervention (PCI) followed by coronary artery bypass grafting (CABG) or staged PCI. Management on MVD coronary artery disease (CAD) should be individualized. We aimed to describe role of PCI in patient with MVD CAD. A 58 y.o female with history of chronic hypertension, T2DM, and ischemic stroke presented to ER with chest and epigastric pain for 12 hours. Associated symptoms were pain radiated to back and nausea. ECG and emergency treatment were done. ECG showed ST elevation on Lead II, III, avF. Emergency management was O2 supplementation, aspirin, clopidogrel, and planned for primary PCI (PPCI). Coronary angiography was done and showed 60% stenosis on RCA, total occlusion on mid LAD with 60% stenosis on prox LAD, and subtotal occlusion with thromboemboli in LCx. LCx was the culprit lesion and intervened with DES with no residue was left. LAD was scheduled for stenting. ST elevation in inferior leads points towards LCx in patients with left dominant coronary circulation. PPCI of LCx (culprit lesion only) was done, as patient was hemodynamically stable. This patient is a Class I ACC/AHA revascularization with CABG because of the presence of T2DM and 3-vessel disease. Instead, the patient was planned for PCI of the remaining vessels. Anatomical consideration in which mid-LAD stenosis was situated at the 2nd diagonal artery will complicate graft attachment and it‟s effectiveness; hence PCI is preferred over CABG. Stenosis in RCA, angiographic wise is insignificant, meaning further intervention is unnecessary. Although study comparing CABG and PCI for MVD CAD showed CABG has better survival rate, individualized approach is a must. In STEMI with MVD, PPCI of culprit lesion is mandatory. Further revascularization with PCI or CABG should be individualized. Keywords: MVD CAD, PCI, CABG 188

Congenital Hernia Diaphragmatica Presenting in A 14- Day-Old Infant : A Case Report Catur Suzantra Sutisna,Valerie Viola, Sri wahyuni Abstract Background : Congenital Hernia Diaphragmatica is a birth defect due to abnormal formation of the muscular parts of diaphragm. Malformation in diaphragma caused protrusion of abdominal contents into the thoracic cavity affecting the normal development of the lungs. Congenital Hernia Diaphragmatica occurs between 1 in 2000 to 1 in 4000 live births. CDH is life theratening condition major cause of death due to two complications: pulmonary hypoplasia and pulmonary hypertension. Case: A 14 day old male infant presented to our emergency room with respiratory distress , physical examination : increased work of breathing and decreased breath sound on the left side of the chest. Laboratory examination leukocytosis.The mother had an antenatal ultrasound that demonstrated normal fetal anatomy. At birth he was asymptomatic but was admitted briefly to other hospital with recurrrent respiratory distress. Intraoperative findings 10 mm defect in the posterolateral diaphragm was discovered and the defect was primarily closed. Now the patient 6 month old shows good response with optimal growth and development. Discussion: In this case late presenting CDH present as a recurrent penumonia, the infant was suffering from a borhaleck type of CDH. In this case prenatal ultrasound is normal because left-sided CDH, usually have smaller defects may not be detected on prenatal screening. Conclusion: In these cases, the diagnosis of CDH may be unsuspected, particularly if the patient has a history of a normal fetal ultrasound and newborn course. This case illustrates one such example and reminds providers to stay vigilant for the diagnosis of late-presenting CDH. 189

Intestinal Malrotation with Midgut Volvulus in Infancy: A Case Report Catur Suzantra Sutisna ,Valerie Viola ,Sri wahyuni Abstract Background: Intestinal malrotation is a congenital disorder in which there is a failure in the rotation of the intestine, especially middle intestine during embryological development. This disorder usually occurs at 10th weeks' of gestation. Intestinal malrotation occurs in about 1: 500 live births, while symptomatic in only 1: 6000 live births. Intestinal malrotation in the infancy is usually diagnosed after signs of intestinal obstruction. In patients, total obstructive ileus has occurred which is a complication of malrotation with volvulus. Case: At present case, a 3 months old boy came to emergency room with bilious vomiting and distended stomach. Patients have a history of delayed meconium. Physical examination: vital signs normal, failure to thrive,distended abdomen, bleeding per rectum. Laboratory findings are normal, while abdomen radiograph showed duodenal and gastric dilatation appears, no air reaches the ileum and the colon is caused by entrapment as high as the duodenum. Plain abdominal radiograph shows an obstructive picture of the level of entrapment in the duodenum. Intraoperative findings malrotation with midgut volvulus. The intestine is dark because of ischemia. The intestine is dark because of ischemia Treatment: patients underwent a standard Ladd procedure with de-rotation of bowel .division of the Ladd bands and placement of the bowel in a nonrotated orientation. Three months later after the procedure, the patient shows good response with optimal growth and development. Discussion: Intestinal malrotation is a congenital anomaly that results from abnormal or incomplete rotation and fixation of the midgut during embryonic development.About 75% to 85% of these patients are diagnosed during infancy. Intestinal malrotation is an emergency that requires immediate surgery. Complications of the intestinal malrotation include sepsis, shock, intestinal obstruction and death. Conclusion: The diagnosis is establish by history of bilious vomiting and distended stomach in infancy with positive physical examination and supported by radiology imaging and intraoperative findings. intestinal malrotation with volvulus is a serious condition that can create serious complication. Immediate surgery should be performed. 190

Combination of Fosfomycin and Levofloxacin for Multidrug-Resistant Pseudomonas aeruginosa Sepsis A Case Report Soroy Lardo, Imelda M. Loho, Indra Wijaya, Khie Chen Lie Abstract Background: Sepsis due to multidrug-resistant (MDR) Pseudomonas aeruginosa is associated with high mortality rates and considerable therapeutic challenge because no new antipseudomonal agents are expected to be available in the near future. Herein we present a case report of sepsis caused by MDR P.aeruginosa which was successfully treated empirically with combination of fosfomycin and levofloxacin. Case Illustration: A 36-year-old man was referred to Indonesia Central Army Hospital Gatot Soebroto from Papua,with diagnosis of severe sepsis and hospital acquired pneumonia after suffering from severe malaria falciparum. He had been treated for one month in an intensive care unit (ICU) with levofloxacin for twenty three days and combination of levofloxacin and meropenem for the last eight days. His sputum culture (taken in our hospital) showed two isolates. First was Pseudomonas spp which was sensitive only to fosfomycin, cefpirome, and cefoperazone. Second isolate was Candida albicans which was sensitive to amphotericin B and imidazole class. Urine culture showed P. aeruginosa which was sensitive to amikacin, fosfomycin, cefpirome, and cefoperazone. The antimicrobial regimen was changed to cefoperazone-sulbactam 1 gram thrice daily,amikacin 1 gram once daily, and intravenous fluconazole 400 mg once daily. On day 9 of ICU therapy, his tracheostomy swab culture detected Pseudomonas aeruginosa which was resistant to all class of antibiotics and intermediately sensitive to cefoperazone. His procalcitonin level increased from 2 to 10 ng/mL and chest x-ray showed new pleural effusion on the left lung. The antibiotic regimen was changed to fosfomycin 2 gram twice daily and levofloxacin 750 mg once daily for seven days. Clinical cure was achieved and his antibiotic regimen was switched to oral cefditoren. Discussion: Fosfomycin, an old class of antibiotic, has been shown in several studies to have a synergistic effect when combined with other antibiotics against P. aeruginosa.Combination of fosfomycin and levofloxacin has been shown to be effective in eradicating sessile cells of P.aeruginosa in biofilm-associated infectious diseases.The effectiveness of 191

fosfomycin combined with levofloxacin against MDR P. aeruginosaisolates, using the efficacy time index assay, was 66,7%. Conclusion: Combination of fosfomycin and levofloxacin could be an alternative option for treating sepsis with MDR P. aeruginosa. Keywords: Sepsis, multidrug-resistant, Pseudomonas aeruginosa, fosfomycin, levofloxacin 192

The Effectiveness of NaI-131 Therapy for Hyperthyroidism (RSPAD Gatot Soebroto Case Report) Eko Purnomo, Djoko Nariman, Ratna D., Yusuf Abstract Introduction: Indonesia described as thousand islands country with multi ethnic. geographic and culture. The incidence of hyperthyroidism is rising in proportion to increasing the health services facility. Common primary therapy for hyperthyroidism are used today : Surgical (hemi lobectomy), Blocking hormone production with anti-thyroid drugs and Radio-ablation or destruction the thyroid with I-131. Selection of therapy depends on a multiplicity of consideration, government support and behavioral of the patients. The low cost safe and effective modalities are that major issue. The all three methods provide satisfactory outcomes in over 91% of patients. The iodine treatments need only 10% surgical costs. Objective : This retrospective study done to evaluate the clinical outcome of treatment of hyperthyroidism using radioactive iodine. Methods : The study total with 236 patients had given I-131 therapy for hyperthyroidism in period between 2005-2008. The dose administered was 8-12 mCi, average 10 mCi. First follow up of them attended 2-3 months after the first dose of I-131. In this study we had tried to find cause of failure of control or therapy of hyperthyroidism, which are about 18% after first dose of I-131 therapy. Among the attended patients treatment failure was more in those patients who had been enrolled failure was 26 (21%). Eight patients required three doses. We have to tried reviewed these patients and try to find out the cause of I-131 therapy failure in initial therapy. We have found following important facts behind therapy dose, I- 131 uptake and its initial quick turnover, size of the gland, nodular and toxicity, chemical drugs, low iodine diet, cell symporter. Conclusion : From the study showed I-131 still effective in the treatment of hyperthyroidism. Our results showed that the majority of patients had an effective treatment. 193

Gingival Depigmentation in Former Smoker Patient, A Case Report Firlina Azrini Abstract Cosmetics dentistry are emerging nowadays toward the patient needs of an esthetic smile. The color of gingiva plays an important role in achieving a pleasant smile along with the presence of proportional shape and color of the anterior teeth. For this reason, an excessive gingival pigmentation become a major esthetic concern for many people. Though, it is usually not a concerning medical problem, many patients complain of dark gums as unesthetic. Gingival hyperpigmentation occurs due to the melanocyte activity producing melanin in the basal layer of the gingiva. It could vary in color from light to dark brown or slightly bluish to black. Racial variance, certain diseases and exposure of several extrinsic substances are factors that determine the severity of this condition. Patients who are smokers produce more melanin to protect the epithelium from the thermal substances in cigarettes. The color intensity of the gingiva from tobacco use depends on the frequency and duration of the smoking activity. This condition called smoker‟s melanosis and can be treated with a surgical procedure to remove the undesired gingival color. Smoker‟s melanosis has been seen among military personals who were in smoking cessation. This case report showed a simple and effective surgical depigmentation of the gingiva in the anterior region of maxilla and mandible using a scrapping technique in former smoker patient. The result showed good healing and preferable outcome in gingival color. Keywords: Gingival hyperpigmentation, Smoker’s Melanosis, Depigmentation 194

Late Onset Type 1 Diabetes Mellitus: A Case Report Bellinda Magdalena, Susie Setyowati Abstract Background: Type 1 diabetes mellitus (T1DM) has emerged as a common and heterogeous condition across the globe. This immune-mediated disease is accounted for ≥85% of all diabetes cases in youth <20 years of age world wide, with its peak between ages 10-14 years during puberty.1 Today the majority of individuals with T1DM are adults, with the rising number of new-onset cases of T1DM in adults as a contributing factor. Case Illustration: A 20 year old man presented with prolonged fatigue, nausea and vomiting. The patient also experinced polyuria, polydipsia, persistent headache, and a 4-kilogram weight loss over the preceding month. There were no pathologic findings on physical examination. He had a body mass index (BMI) of 17.1 kg/m2, random plasma glucose level 855mg/dL, positive serum ketone, glycated hemoglobin 17.7%, basal C- peptide <0.5ng/mL and GAD-65 <5IU/mL. The patient reported no family history of diabetes. Treatment was successful with IV fluids and insulin for diabetic ketosis. He was discharged from the hospital 15 days later on 10IU of insulin aspart 3 times a day and 20IU of insulin glargine at night with controlled glucose level (117mg/dL). Discussion: The diagnosis of T1DM is usually made on clinical grounds such as hyperglycemia, ketosis, BMI <25kg/m2 and personal and/or family history of autoimmune disease.3 The NICE Guideline 2015 suggested the measuring of C-peptide and/or diabetes-specific autoantibody titres if the classification of a patient is still uncertain. A low C-peptide and/or a positive autoantibody supports the diagnosis of T1DM. Of the four known autoantibodies, GAD-65 is one of the most commonly measured antibodies in diagnosing T1DM in adults. Compared to Caucasians, studies have shown a higher prevalence of Asian type-1 diabetic patients to be antibody- negative. This state of being antibody-negative does not exclude the diagnosis of T1DM and does not alter the therapeutic regimens. Studies conducted in Singapore suggested the evaluation of islet antigen 2 antibodies for further evaluation of autoimmunity status in Asian type-1 diabetic patients. Conclusion: This patient is clinically defined as a type-1 diabetic patient with no evidence of autoimmunity. Further studies on this patient may contribute to signs of autoimmunity. 195

Helcobacter pylori Infection in Siblings : A Case Report Mardiastuti H.Wahid, Lisa Yuliantiningsih, Rike Syahniar, Ari Fahrial Syam, Andi Yasmon, Ening Krisnuhoni, Ardiana Kusumaningrum and Angky Budianti Abstract Helicobacter pylori infection is still prevalent worldwide. A study on H. pylori infection in 12 countries in Asia and the middle east showed a wide range of prevalence. With the highest found in Australia (African refugees) Indonesia is a country with a thousand islands and variety of ethnic groups. A study in the five biggest island of Indonesia revealed that the prevelance of H. pylori infection was 22,1 %. Although the predominant ethnic group in Indonesia is Javanese, the most commontly affected ethnic groups are Papauan, Batak and Buginese. Another study in urban areas found a higher prevelance of 68%. The mode of transmission of H.pylori infection is not well known. It is assumed that the major mode of transmission within a family is direct person to person contact. Here, we present the case of four siblings who had H.pylori infection. The patients were from a family originating from The Bataks tibe (North Sumatra). They complained of dyspepsia. Endoscopic examination revealed that three of them had gastritis. While one had normal gastric tissue. In addition, histopathological examination of three siblings. 196

Case Report : Plasma Convalescent Therapy in Severe Patient COVID-19 Basuki Rachmad Abstract There are insufficient data to recommend for the use of COVID-19 Convalescent Plasma (CP) . From January 23, 2020, to February 19, 2020, there were 10 severe COVID-19 patients (six males and four females) were enrolled and received CP transfusion. The average age of the patients was 52.5 years old. The symptoms most often are fever, coughing, shortness of breath, chest pain, disappearing or mostly improving within 1 to 3 days after CP transfusion. In this study, 2 severe patients confirmed by real-time viral RNA test were enrolled prospectively. One dose of 100 mL of convalescent plasma (CP) derived from recently recovered donors was transfused to the patients as an addition to maximal supportive care and antiviral agents. The primary endpoint was the safety of CP transfusion. The second endpoints were the improvement of clinical symptoms and laboratory parameters within 3 d after CP transfusion. After CP transfusion, the clinical symptoms were significantly improved along with increase of oxyhemoglobin saturation within 3 days. Several parameters tended to improve as compared to pretransfusion, including increased lymphocyte counts, decrease NLR counts, decreased C-reactive protein, and decreased procalcitonin. Radiological examinations showed varying degrees of absorption of lung lesions within 7 days. We found from our case that treatments that had been used with Convalescence transfusion therapy looked promising. Keywords: COVID-19, Plasma Convalescent Transfusion 197

Modification Technique in Post-Myocardial Infarction Ventricular Septal Defect Closure: A Case Report Sheilla Giusti, Aulia Rahman, Aswin Nugraha, Andreas Andri Lensoen, Wijoyo Hadi Mursito, Arief Widya Taufiq Abstract Introduction: A post-myocardial infarction (MI) ventricular septal defect (VSD) is a rare case with high operative mortality, high rate of residual- recurrent shunt, and deceased long-term survival. There are many techniques of post-myocardial infarction VSD closure have been described to address the frality of the tissues and prevent recurrent residual VSD. Case Description: We Have a case of 55th years old Male with a Post- Myocardial Infarction Ventricular Septal Defect after seven days onset of Acute Anterior Myocardial Infarction who underwent a Ventricular Septal Defect Closure and Coronary Artery Bypass Graft. The VSD was confirmed by a transthoracic echocardiography, showing 0.7-1.5cm gap in mid anteroseptal wall. The operation was done on the third week after admission, with modification technique of Ventricular Septal Defect Closure. Discussion: In this case, we describe a modification of the infarct exclusion technique using a single patch and eight pledgets. Four pledgets for securing the patch and the other four was to tighten the VSD gap. Conclusion: There are many different techniques that have been used successfully to repair post infarction VSD. Although the outcome of this modification technique was good, further research about this technique has to be done to evaluate the incidence of recurrent VSD. Keywords: Postinfarction, Ventricular Septal Defect, Ventricular Septal Rupture, Myocardial Infarction Complication, Cardiac Surgery 198

Malaria and Co-Infection Among Traveller in A Refferal Hospital: A Case Series Soroy Lardo, Hadiki Habib, Rahmat Cahyanur, Donnie LG Abstract Introduction: A referral hospital in tropical region often received referral malaria patient with many co infection undiagnosed and have no respon to the therapy from the local hospital. Because of the indaquate therapy before, the referral patient usually have atypical sign and symptoms. The epidemiology of infection from the region where patient stay should take into consideration because patient could have multiple infection.Here we report a case series of three refferal patients of Gatot Subroto Central Army Hospital Jakarta, Indonesia with mix falciparum and vivax infection, falciparum and H1N1, vivax and dengue. Case 1 was a male patient with sudden onset of continuous high grade fever for three days. He was an army on duty referred from local hospital in Papua, an endemic malaria region. He also had chilled and diaphoresis. The laboratory result was pancytopenia, positive IgM anti dengue, and positive vivax from peripheral blood smear. Case 2 was a male patient with flu like illness for three day and he just arrived from pantai gading an endemic malaria region, no history of animal contact. At presentation in referral hospital, his laboratory result was pancytopenia. The laboratory result for oropharyngeal swab is positive for H1N1 infection, and his rapid malaria test was positive falciparum. Case 3 was a male patient with mixed malaria infection with falciparum and vivax. The vivax parasite was detected on pheripheral blood smear one month after finished falciparum treatment. The vivax and falciparum parasite was undetected at first presentation in referral hospital due to kina treatment in local hospital, but the IDT for falciparum was (+) and the peripheral blood was pancytopenia, patient was a traveler in East Borneo and never had malaria before. Discussion: All patient is male, they came from the endemic Malaria region and have fever-chill-diaphorised symtoms typical for malaria. Patient number 3 had severe malaria and he had never malaria infection before. Plasmodium falciparum and vivax are the two most common malaria infection and can cause mix infection.This mix infection induced many clinical implication and difficult to diagnose because falciparum parasitemia inhibit vivax parasitemia and vice versa. Based on these three cases, a referral hospital should reevaluate reffered patients including their history of 199

travel, history of animal contact, epidemiology of disease in origin country, did more complete laboratory examination, and treat patient more adequate. Conclusion: A Refferal hospital in Indonesia as one of tropical country could have reffered patients with multiple infection with vary clinical manifestation. One clinical condition could be more prominent than other in one patient, lead to a miss in diagnostic. A careful examination, including taking information of history of travel, epidemiology, and complete laboratory examination could detect the other hidden infection. 200

Prolonged Severe Thrombocytopenia as Complication of African Vivax Malaria Resembled Immune Thrombocytopeniepurpura Soroy Lardo, Laurentius A Pramono, Nikko Darmindro, Jerry Nasaruddin, Mala Hayati, Bhanu Kumar, Prima Yuriandro, Rizki Y Pradwipa, Nyoto W Astoro Abstract Background: Althought not acriteria for severe malaria, thrombocytopenia is an important hematology manifestation in malaria. Severe thrombocytopenia is unusual in vivaxmalaria compared to other types of malaria. The prevalence is only 3,6 % among adult patiens with vivaxmalaria. Not many have been reported world widely, until now, report are only comes from India and Brazil. This is the first case reported from Indonesia. Objective: Prolonged severe thrombocytopenia can occur as complication of vivax malaria. One suspect about this as immune thrombocytopenia purpura. Methods : We report a case of 29th year old Inonesian army with prolonged severe thrombocytopenia, he entered the hospital with chronic fatique and bleeding from gum and skin, but there is not fever, chilling and sweating. He just came from a duty in Kongo, Africa teo months before with history of vivax malaria, previously, he got artesunate regimen. Results: hes thrombocyte count reaches the level of 5000 and his malaria blood smear is negative. First, we suspect him immune thrombocytopenic. The thrombocyte count still low, maximum is 12.000 after giving steroid and immunosuppressant therapies. For prevent bleeding, we also give thrombovyte transfusion for him, after one month, we re checked his blood smear and found positive plasmodium vivax, after giving him a regimen of malaria treatment with artesunate and primaquin, the thrombocyte increase day-by-day to 47.000 with increasing trend. Conclusion: From the case, we can learn how prolonged severe thrombocytopenia can occur as complication of vivax malaria, Negative clinincal manifestation and blood smear of malaria does not rule out the infection status. From detail and serial laboratory examinations. We can get the true diagnosis and give the patients definitve treatment for vivax malaria. Keywords: Prolonged severe thrombocytopenia, vivax malaria, complication, Indonesia army 201

A Re-Positive Covid-19 Patient Yongkie Iswandi Purnama, Soroy Lardo Abstract A 38-years old female was re-admitted secondly due to re-positive nasopharingeal swab for RT-PCR CoV-2. During this second readmission she did not have any symptoms. Chest X-ray reveal pneumonia. She also has history of type 2 diabetes mellitus. Angiotensin-converting enzyme-2 (ACE-2) as the entry receptor of SARS- CoV-2, much more located at lungs than upper respiratory tract. Bronchoalveolar lavage specimen for RT-PCR SARS-CoV-2 test will have more accurate result but also with higher risk of contamination. Patients with negative RT-PCR SARS-CoV-2 from respiratory tract specimen also still have possibility of positive result if the specimen is taken from rectal swab. Study revealed that RT-PCR SARS-CoV-2 from rectal swab specimen will give more benefit to decide therapeutic effect and whether we can stop patient quarantine. Until February 2020, there were not studies that concluded about the infectious period of Covid-19 patient. In some countries, they have Covid- 19 management protocols state that patient will be discharged although with positvie RT-PCR SARS-CoV-2 after 14-21 hospitalization. Guideline is needed to be the foundation for deciding when Covid-19 patient can be discharged. This is can be related to the risk of contamination in the patient‟s neighborhood, moreover if there is law pursuit in the future. Keywords: Covid-19, nasopharingeal swab, RT-PCR CoV-2, re-positive 202

Case Report of Baby Born with Goltz Syndrome Diana Chaidir, Fransiskus Aditya Kristianto, Catur Suzantra Sutisna, Irhamni, Anastasia Dessy Harsono, Sri Dharmayanti, Rita Maria, Yenny Purnama, Yenny Kumalawati Santoso, Windhi Kresnawati Abstract Background : Goltz syndrome also known as focal dermal hypoplasia is a rare genetic condition characterized by multisystem disorder due to mutations in the PORCN gene in the chromosome Xp11.23. Approximately 300 affected individuals have been reported worldwide since 1962 and this syndrome occurs predominantly in females with 9:1 ratio. This case would describe the diagnosis approach and multidisciplinary treatment to achieve a better outcome. Case : A female full term baby born of non-consanguineous marriage presented with multiple congenital anomaly. She had low set ear, deformed pinna, right-sided facial deformity, microphtalmia with chorioretinal coloboma, multiple linear atrophied hypo- and hyperpigmented macules, lobster claw hand, omphalocele, multiple excoriation and bullae (neck, thigh and gluteal area), fat herniation on lower limb, and bladder extrophia. The baby gram showed agenesis of ulnar bone, single phalanx of left hand and 2 phalanx of right hand. Histopathology showed dermal hypoplasia, high adipocytes tissue in dermis, and lessening collagenous fiber. The omphalocele and bladder extrophy was surgically corrected. The blisters and ulcers were treated with emollient and topical antibiotic. She was discharged on day 35. At 4-month old follow up visit, the baby was doing well with normal development. Routine visit was scheduled for developmental, cognitive ability, and behavior difficulties evaluation. Conclusion: Despite a lot of congenital anomaly, the prognosis of Goltz syndrome is quite good. Histopathology is the most specific diagnostic tool for Goltz syndrome. A comprehensive and multidisciplinary team work (pediatrics, dermatologist, surgeon) is required to perform early intervention and routinely monitored systemic problems. Keywords : Focal dermal hypoplasia, Goltz Syndrome, Pediatrics 203

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